Get Or Legacy Laboratory Services Prenatal Screening Requisition 2016

Filling out the OR Legacy Laboratory Services Prenatal Screening Requisition accurately is essential for proper prenatal screening. This guide provides clear and concise instructions to help users complete the form online with ease.

Follow the steps to complete the online requisition form.

1. Click ‘Get Form’ button to obtain the form and access it in your document management system.
2. Fill out the clinic name, provider name, and contact information. This includes entering the clinic's address and phone number in the designated fields.
3. Enter the patient’s legal name in the format of last name, first name, and middle initial. This field is marked as required.
4. Provide the patient’s date of birth in the specified format. Make sure this information is accurate as it is crucial for screening purposes.
5. Input the last four digits of the patient’s social security number in the designated field.
6. Select the gender of the patient by marking either 'male' or 'female'.
7. Complete the collection date field to indicate when the specimen will be collected.
8. Fill in the patient’s home address, ensuring all required information is accurate.
9. Enter the diagnosis code(s) as necessary for your patient’s condition, using the specific format provided.
10. Select the appropriate prenatal screening option from the first and second trimester categories by checking the relevant boxes.
11. Provide the required information regarding the mother’s ethnicity and weight, ensuring to input numbers as required.
12. Add the estimated date of delivery and specify how it was determined. Also note the number of fetuses and any related details regarding chorion type.
13. Answer the questions about the patient's medical history and pregnancy specifics, marking yes or no as applicable.
14. For additional required information, such as previous pregnancy details or specific conditions (like neural tube defects), complete those fields carefully.
15. Include any additional information for the first and second trimester screens, only if applicable.
16. Ensure an authorized signature is provided along with the date before submission. This is required for all faxed lab orders.
17. Review all filled sections to confirm accuracy and completeness before final submission.
18. Save changes, download, print, or share the form as needed once all information is verified.

Complete your OR Legacy Laboratory Services Prenatal Screening Requisition online now to ensure timely and accurate prenatal care.